In high-risk environments like the operating theatre, situational awareness and anticipatory thinking are essential. While standard safety protocols such as checklists and briefings are now routine, some surgeons have adopted an additional layer of safety: verbalising anticipated errors at key stages of surgery. This proactive technique, though informal and inconsistently adopted, has been observed to sharpen team focus, reduce the likelihood of mishap, and promote collective awareness during complex procedures.
It is therefore affirming to note that this very practice—known in Japan as Pointing and Calling (Shisa Kanko)—is already embedded and widely employed in high-stakes industries such as rail and aviation, where it has demonstrated striking effectiveness in reducing human error (https://youtu.be/RZun7IvqMvE?si=3TbWsamePGl9IFza).
What is Pointing and Calling?
Pointing and Calling involves physically pointing at a critical object or parameter and simultaneously verbalising its name or state before taking action. For example, a Japanese train driver will point at a speedometer and say the speed aloud before confirming a control input. This ‘ritualistic confirmation’ creates a multisensory engagement—visual, auditory, and motor—that improves attention and reduces oversight.
Evidence of Impact
Research from the Japanese Railway Technical Research Institute shows that Pointing and Calling can reduce errors by up to 85% in repetitive task settings. Additional studies confirm its utility even when tasks are routine or unchanged, due to its role in reinforcing attentional control and reducing cognitive slips. Notably, despite the extra physical actions involved, users do not report an increased sense of workload.
Parallels in Surgery
In surgery, a comparable practice already exists among some surgeons: deliberately verbalising the potential pitfalls or risks during distinct procedural phases. For example, a surgeon may say aloud, “This is the common bile duct—risk of injury here,” or, “Risk of bleeding as we divide this plane.” These utterances serve not only as personal prompts but also cue the entire team to heighten vigilance and anticipate the next steps.
Such verbalisation operates in the same cognitive space as Pointing and Calling—bringing intention and risk into the open, using the body and voice to anchor thought in action. It externalises awareness, reducing dependence on silent internal memory and instead engaging the collective focus of the operating team.
Why Broader Use Matters
Given the mounting complexity of modern surgery—minimally invasive techniques, robotic platforms, multidisciplinary teams—anything that enhances real-time safety awareness is worth pursuing. Pointing and Calling offers a structured, embodied tool for precisely that. Its broader use in surgical theatres could standardise the informal yet effective habits already in place among some surgeons.
The challenge may lie in cultural barriers: fear of seeming overly cautious, reluctance to appear theatrical, or simply unfamiliarity with the technique. Yet these can be addressed through training, modelling, and integration into existing safety culture.
Conclusion
Verbalising potential surgical mishaps is already practised with benefit by some surgeons. Recognising its alignment with the well-established method of Pointing and Calling in other high-stakes domains reinforces its value. Far from being superfluous, this embodied rehearsal of intention and caution should be viewed as a cognitive safety net—one we would do well to adopt more widely in the operating theatre.
Surgery Talks 